Second Identified Human Infection With the Avian Influenza Virus H10N3: A Case Report
Authors: Weimin Zhang, Zhongheng Zhang, Maofeng Wang, Xinling Pan, Xuandong Jiang
Journal: Annals of Internal Medicine (2023)

LettersMarch 2023Second Identified Human Infection With the Avian Influenza Virus H10N3: A Case ReportFREEWeimin Zhang, MD, Zhongheng Zhang, MD, PhD, Maofeng Wang, MD, PhD, Xinling Pan, MD, PhD, Xuandong Jiang, MDWeimin Zhang, MDIntensive Care Unit, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China, Zhongheng Zhang, MD, PhDDepartment of Emergency Medicine, Sir Run Zongyang Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China, Maofeng Wang, MD, PhDDepartment of Biomedical Sciences Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China, Xinling Pan, MD, PhDDepartment of Biomedical Sciences Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China, Xuandong Jiang, MDIntensive Care Unit, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, ChinaAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/L22-0376 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Influenza viruses are classified into types A, B, C, and D. Types A and B are further classified into subtypes based on which single hemagglutinin (H) and neuraminidase (N) they have of the many possible ones. Only 2 subtypes of influenza A virus (H1N1 and H3N2) are currently circulating in humans; however, many subtypes of influenza A virus have been found in wild aquatic birds, wild waterfowl, and poultry (1). These subtypes are known as avian influenza viruses (AIVs).Transmission of AIV from birds to humans can sometimes occur, but subsequent human-to-human transmission has been rare and has been limited when it has occurred. Extensive human-to-human transmission would be a global public health concern. Recently, new subtypes of AIV with the H10 hemagglutinin have been identified (2). The only reported human infection with the H10N3 subtype occurred in a patient in Jiangsu Province, China, in April 2021 without recognized human-to-human transmission (3).Objective: To report a second human infection with the H10N3 subtype of AIV.Case Report: A 32-year-old previously healthy man who had a history of fatty liver disease and was being treated at his local health center was admitted to a hospital in China's Zhejiang Province on 18 June 2022 with a 1-week history of cough; hemoptysis; fever; and yellow, watery stools. He raised chickens and ducks at home and worked in a slaughterhouse that processed sheep. He had not been in contact with anyone who had respiratory symptoms during that month.His vital signs on admission included a pulse rate of 112 beats/min, respiratory rate of 20 breaths/min, blood pressure of 94/67 mm Hg, and temperature of 38.9 °C. Auscultation found coarse breath sounds in both lungs with wet rales in the left lung, and percussion produced clear sounds bilaterally. Laboratory test results included a leukocyte count of 2.87 × 109 cells/L (reference, 4.0 to 10.0 × 109 cells/L), a neutrophil percentage of 80.2% (reference, 40% to 75%), a lymphocyte percentage of 16% (reference, 20% to 40%), a procalcitonin level of 0.809 ng/mL (reference, <0.5 ng/mL), and a high-sensitivity C-reactive protein level of 151.7 mg/L (reference, 0.5 to 10 mg/L). Chest computed tomography revealed multiple ill-defined patchy shadows with consolidation and small bilateral pleural effusions (Figure 1). We diagnosed severe pneumonia and type 1 respiratory failure and transferred the patient to the intensive care unit, where he received high-flow respiratory oxygen, enhanced antibiotic therapy, and hydrocortisone (80 mg every 8 hours). On 21 June, next-generation sequencing of material in the bronchoalveolar lavage fluid identified AIV H10N3 (Dean Medical Laboratory Center, Hangzhou, China), and oseltamivir phosphate (75 mg twice daily) was initiated. The identity of the virus was confirmed 3 days later by the Zhejiang Provincial Centre for Disease Control and Prevention. The patient's condition improved, and he was discharged on 4 July. Follow-up computed tomography on 30 August showed absence of the lung lesions.Figure 1. Lung computed tomography findings during hospitalization on 18 June 2022.The findings included multiple ill-defined patchy shadows with consolidation and small bilateral pleural effusions. Download figure Download PowerPoint The phylogenetic tree built on HA sequences of all H10N3 strains from China showed that the H10N3 strain in this patient was in the same group as the H10N3 strains from the first case in Jiangsu and from chickens from different provinces (Figure 2). The H10N3 strain from the first case was closer to strains from poultry, whereas the hemagglutinin sequence of our case had 31 nucleotides (causing 10 amino acid mutations) that differed from those in the first case. It also had internal viral genes of H9N2, as shown by homological analysis.Figure 2. Phylogenetic tree of 55 H10N3 strains from China.The tree was downloaded from the GISAID database (https://gisaid.org) using the neighbor-joining method in MEGA X. The triangle indicates the H10N3 strain in this study, and the circle indicates the H10N3 strain from the first case in Jiangsu. Download figure Download PowerPoint Discussion: These findings confirm that the H10N3 subtype of AIV can infect healthy adults. To identify the source of infection, the Centers for Disease Control and Prevention in Zhejiang Province tested multiple possible sources at the patient's workplace and among his poultry but found no H10N3 virus. Our patient had not recently visited Jiangsu, where the first case occurred. Both patients had contact with live poultry and presented with severe pneumonia. In addition, both H10N3 viruses had mutations of the hemagglutinin gene that are present in H10N7 and H10N8 subtypes, which means that the binding affinity for human receptors in these 2 H10N3 viruses should prevent human-to-human transmission (4). Moreover, the H10N3 virus in our patient contained internal viral genes with high homology to comparable genes from the H9N2 virus, which indicates that it resulted from viral reassortment (5). Finally, the high homology in the viruses from these 2 cases and the viruses in poultry suggests sporadic transmission from poultry.References1. Lycett SJ, Duchatel F, Digard P. A brief history of bird flu. Philos Trans R Soc Lond B Biol Sci. 2019;374:20180257. [PMID: 31056053] doi:10.1098/rstb.2018.0257 CrossrefMedlineGoogle Scholar2. Chen H, Yuan H, Gao R, et al. Clinical and epidemiological characteristics of a fatal case of avian influenza A H10N8 virus infection: a descriptive study. Lancet. 2014;383:714-21. [PMID: 24507376] doi:10.1016/S0140-6736(14)60111-2 CrossrefMedlineGoogle Scholar3. Qi X, Qiu H, Hao S, et al. Human infection with an avian-origin influenza A (H10N3) virus [Letter]. N Engl J Med. 2022;386:1087-8. [PMID: 35294820] doi:10.1056/NEJMc2112416 CrossrefMedlineGoogle Scholar4. Schneider EK, Li J, Velkov T. A portrait of the sialyl glycan receptor specificity of the H10 influenza virus hemagglutinin—a picture of an avian virus on the verge of becoming a pandemic. Vaccines (Basel). 2017;5. [PMID: 29236069] doi:10.3390/vaccines5040051 CrossrefMedlineGoogle Scholar5. Gao R, Zheng H, Liu K, et al. Genesis, evolution and host species distribution of influenza A (H10N3) virus in China [Letter]. J Infect. 2021;83:607-35. [PMID: 34416256] doi:10.1016/j.jinf.2021.08.021 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Intensive Care Unit, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, ChinaDepartment of Emergency Medicine, Sir Run Zongyang Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, ChinaDepartment of Biomedical Sciences Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, ChinaNote: The patient provided informed consent for publication of this case report.Acknowledgment: The authors thank Dr. Yanjun Zhang for his invaluable help in providing information from the Centers for Disease Control and Prevention in Zhejiang Province. The authors also thank Editage for English-language editing.Grant Support: This research was supported by the Zhejiang Medical Association (grants 2018ZYC-A134 and 2020ZYC-B44).Disclosures: The authors have reported no disclosures of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L22-0376.Corresponding Author: Xuandong Jiang, MD, Intensive Care Unit, Affiliated Dongyang Hospital of Wenzhou Medical University, No. 60 Wuning West Road, Dongyang, 322100, Zhejiang, China; e-mail, [email protected]com.This article was published at Annals.org on 24 January 2023. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Current IssueMarch 2023Volume 176, Issue 3Page: 429-431KeywordsAvian influenzaBronchoalveolar lavageHospital medicineIntensive care unitsLungsPathogensPleural effusionPneumoniaRespiratory failureTemperature ePublished: 24 January 2023 Issue Published: March 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...